CPT 2 Coding Review Jim Barr, MD Medical Director, Atlantic & Optimus ACO’s Bridget McKenzie RN, MSN Director Business Advisor Services-Population Analytic Marlene Smith RN, MBA Business Advisor

© 2013 McKesson Corporation. Confidential and proprietary. CPT 2 Codes Overview 06.11.2018 © 2013 McKesson Corporation. Confidential and proprietary. (c) 2011 MedVentive Inc. All rights reserved. Proprietary and confidential. 2

CPT 2 Codes Overview What are CPT 2 Codes? CPT 2 codes define certain quality-related clinical services that you perform during regular patient encounters (BMI measurement, tobacco use screening, BP measurement) . By including these codes within your “services provided” on an insurance claim, they can deliver necessary documentation that you are performing and managing specific quality indicators. Through evidence-based research, the services defined by CPT 2 codes have been linked to quality patient care and are therefore used to support nationally established performance programs ( like PQRS and ACO quality measurements). In addition, CPT 2 codes can describe results from clinical laboratory or radiology tests and other procedures, identify patient safety processes, or services reflecting compliance with state or federal law. The CPT 2 codes do not have a charge or reimbursement associated with them. They only describe certain clinical services performed during patient encounters or results from certain processes. The codes are not required for standard claims generation and may not be used as a substitute for basic CPT 4 CPT is a registered trademark of the American Medical Association. Copyright 2013 American Medical Association. All rights reserved. (Last Updated Apr. 19, 2013) 11/6/2018

CPT 2 Codes Overview Why do we use them within the ACO? Quality measurement is a required component of all ACO contracts and many P4P (pay for performance) compensation models like PQRS. Physicians need to submit documentation identifying certain services they perform and test results they ordered relating to the required quality metrics to meet contracts or quality program requirements. Allow physicians to document their quality performance via the CPT coding system in their practice management systems and on their claims submitted to payers The use of these codes is optional but provides an efficient method for physicians to submit documentation of the required quality reporting. In quality performance reports, the CPT 2 codes supplies the numerator and usually the ICD-9-CM and CPT Category I codes supply the denominator. CPT is a registered trademark of the American Medical Association. Copyright 2013 American Medical Association. All rights reserved. (Last Updated Apr. 19, 2013) The use of the CPT 2 codes will simplify the physician's office workflow AND will require less chart review and data mining in the future 11/6/2018

CPT 2 Code Categories CPT 2 Categories Composite Measures 0001F – 0015F Therapeutic, Preventive, or Other Interventions 4000F – 4306F Patient Management 0500F – 0575F Follow-Up or Other Outcomes 5005F – 5100F Patient History 1000F – 1220F Patient Safety 6005F – 6045F Physical Examination 2000F – 2050F Structural Measures 7010F – 7025F Diagnostic/Screening Processes/ Results 3006F – 3573F G codes Modifiers: Such as 1P, 2P and 3P or G-codes are available to describe medical, patient, system, or other reasons for performance exclusion. 11/6/2018 McKesson Corporation Confidential and Proprietary

CPT 2 Codes For CMS MSSP Quality Measures Con CPT 2 Codes For CMS MSSP Quality Measures 06.11.2018 © 2013 McKesson Corporation. Confidential and proprietary. (c) 2011 MedVentive Inc. All rights reserved. Proprietary and confidential. 6

CMS MSSP ACO Quality Measures MSSP=Medicare Shared Savings Program 22 Quality measures that require provider submission to CMS CPT 2 codes is consistent with the CMS 2013 Quality documentation codes (QDC) set 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Care Measures with no CPT 2 codes for performance Daily Aspirin with Diabetes & Ischemic Heart –DM 11/GPRO 314 (ACO-26) This measure requires manual entry or an EMR code HBA1c <8 – DM 10/GPRO 313 (AC0-22)  There is no CPT2 code that means HbA1c<8.  This measure uses manual entry, lab data with results, or EMR data Both of these measures are included in the all-or-nothing Diabetes Optimal Care Composite

© 2013 McKesson Corporation. Confidential and proprietary. Sample Slide 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Other Performance Exclusion Performance Not Met Official Measure Title: Official measure description PQRS # ACO # MEASURE Patient presentation scenario or metric description goes here in the blue text Meets Performance CPT2— Criteria description Other Performance Exclusion CPT2— Criteria description Performance Not Met CPT2— Criteria description F code Modifiers are available: -1P Medical reason -2P Patient reason -8P No reason documented 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Preventive Care 8 Measures Individually Sampled 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Performance Exclusion Performance Not Met Preventive Care and Screenings: Influenza Immunization #110 ACO-14 MEASURE Patient presents for an office visit with Dr. Smith during the time period October 1st – March 3rd and is 6 months of age or older. Meets Performance G8482—Influenza immunization administered or previously received (may include receipt from another provider or receipt prior to October 1st) Performance Exclusion G8483-Influenza not administered for documented reasons, AND 4037F-1P – Medical reason not administered (allergy), OR, 4037F-2P – Patient reason not administered (declined) G0919-Influenza immunization ordered or recommended , but vaccine not available Performance Not Met G8484—Influenza immunization was not ordered or administered; reasons not specified 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Medical Performance Exclusion Performance Not Met Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older #111 ACO-15 MEASURE Patient presents for an office visit with Dr. Smith and is 65 years of age or older Meets Performance 4040F—Pneumococcal vaccine administered or previously received Medical Performance Exclusion 4040F-1P—Documentation of medical reasons for not administering or previously receiving pneumococcal vaccination Patient refusal is not acceptable Performance Not Met 4040F-8P – Pneumococcal vaccination not administered or previously received, reason not specified 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Other Performance Exclusion Performance Not Met Body Mass Index (BMI) Screening and Follow-Up #128 ACO-16 MEASURE % of patients with a calculated BMI in the past 6 months or during the current visit, and if outside normal parameters a follow-up plan is documented. Normal BMI for age 65 is 23 to <30. Normal BMI for age 18-64 is 18.5 to <25 Meets Performance G8420—BMI calculated as normal, no follow-up plan required OR G8417—BMI calculated above normal parameters, follow-up documented G8418—BMI calculated below normal parameters, follow-up documented Other Performance Exclusion G8422—BMI not calculated, patient not eligible/ or not appropriate Examples: Patient receiving palliative care Patient is pregnant Patient refuses BMI Patient has an urgent condition Performance Not Met G8421—BMI not calculated, reason not given OR G8419—BMI calculated outside of normal parameters, follow-up plan not documented, reason not given 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Medical Performance Exclusion Performance Not Met Preventive Care and Screening: Tobacco Use — Screening and Cessation Intervention #226 ACO-17 MEASURE % of patients 18 years and older screened for tobacco use one or more times within 24 months, AND who received cessation counseling intervention if identified as a tobacco user (any type of tobacco) Meets Performance 4004F—Patient screened for tobacco use AND received tobacco cessation (intervention, counseling, pharmacotherapy, or both), if identified as a tobacco user. OR 1036F—Patient screened for tobacco use and identified as a non user of tobacco Medical Performance Exclusion 4004F-1P—Tobacco Screening not performed for Medical Reasons (i.e. limited life expectancy, other medical reason) Performance Not Met 4004F-8P - Tobacco screening not performed, reason not identified 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Other Performance Exclusion Performance Not Met Screening for Clinical Depression and Follow-up #134 ACO-18 MEASURE % of patients 12 years and older screened for clinical depression using a standardized tool AND, if positive, a follow-up plan is documented. Meets Performance G8431—Positive screen for depression documented, follow-up plan documented OR G8510—Negative screen for depression documented, follow-up plan not required Other Performance Exclusion G8433—Screening for depression not documented, patient not eligible/ appropriate/ refuses (active dx, urgent care) G8940—Screening for depression documented, follow-up plan not documented patient not eligible/ appropriate/ refuses Performance Not Met G8432—Screening for depression not documented, reason not given OR G8511—Screening for depression documented, follow-up plan not documented, reason not given 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Medical Performance Exclusion Performance Not Met Colorectal Cancer Screening #113 ACO-19 MEASURE Patient presents for an office visit with Dr. Smith. Age 50-75 % with FOBT within 12 months / Flex Sig within 4 years / Colonoscopy within 10 years Meets Performance 3017F—Colorectal Cancer screening results documented and reviewed Medical Performance Exclusion 3017F-1P—Colorectal cancer screening documentation of medical reasons not performed (e.g.total colectomy) Patient refusal is not an exclusion Performance Not Met 3017F-2P – Patient refuses 3017F-8P – Colorectal cancer screening not performed, reason not documented 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Medical Performance Exclusion Performance Not Met Breast Cancer Screening #112 ACO-20 MEASURE Patient presents for an office visit with Dr. Smith Female aged 49 – 69 % with Mammogram within 24 months Meets Performance 3014F—Screening mammography results documented and reviewed Medical Performance Exclusion 3014F-1P—Mammography not performed for medical reasons (i.e. women who had a bilateral mastectomy) Patient refusal is not an exclusion Performance Not Met 3014F-2P - Screening mammogram not performed, patient refuses 3014F-8P – Screening mammogram not performed, reason not documented 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Other Performance Exclusion Performance Not Met Screening for High Blood Pressure #317 ACO-21 MEASURE Patient 18 years of age or older presents for an office visit with Dr. Smith. % of patients with a blood pressure measurement at least once per reporting period AND a recommended follow-up plan is documented based on current BP reading Meets Performance G8783—Normal BP reading documented, follow-up not required OR G8950—Pre-hypertensive or hypertensive BP reading documented, indicated follow-up documented Other Performance Exclusion G8784—Reading not documented, patient not eligible/not appropriate (active dx, refuses, or urgent care) OR G8951—Pre-hypertensive or hypertensive BP reading documented, indicated follow-up not appropriate Performance Not Met G8785—BP reading not documented, reason not given OR G8952—Pre-hypertensive or hypertensive BP reading documented, indicated follow-up not documented, reason not given <120 and <80 PreHTN <140 or <90 (lifestyle Rx and rescreen within 1 yr, or referral) Newly dx HTN >140 or >90 (rescreen within 1-28 days and lifestyle rx, or referral), 2nd time HTN reading (Rx, lab, ECG, referral) 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

© 2013 McKesson Corporation. Confidential and proprietary. Composite Disease Module Optimal Diabetes Care 5 Measures All or Nothing Reporting 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

© 2013 McKesson Corporation. Confidential and proprietary. Diabetes Composite: Control in Diabetes Mellitus A1c <8 #313 ACO-22 MEASURE Diabetic patient age 18-75, with 2 or more visits for diabetes in last 2 years, and at least one visit for any reason in the last year. Meets Performance No code available. Performance Exclusion PCO, Gestational Diabetes, Steroid Induced Diabetes Need to check on any available CPT 2 codes for this 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

© 2013 McKesson Corporation. Confidential and proprietary. Diabetes Composite: Low Density Lipoprotein (LDL- C) Control in Diabetes Mellitus #002 ACO-23 MEASURE Patient age 18-75 presents for an office visit with Dr. Smith and has a diagnosis of diabetes Meets Performance 3048—Most recent LDL <100 mg/dL OR 3049F—Most recent LDL-C 100-129 mg/dL 3050F—Most recent LDL-C >130 mg/dL Performance Exclusion PCO, Gestational Diabetes, Steroid Induced Diabetes 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

© 2013 McKesson Corporation. Confidential and proprietary. Diabetes Composite: High Blood Pressure Control in Diabetes (Two CPT2 codes must be recorded) #003 ACO-24 MEASURE Patient age 18-75 presents for an office visit with Dr. Smith and has a diagnosis of diabetes Meets Performance G8919—Most recent systolic BP measurement performed <140 mmHg OR G8920—Most recent systolic BP >140 mmHg AND G8921—Most recent diastolic BP <90 mmHg G8922—Most recent diastolic BP >90 mmHg Performance Exclusion PCO, Gestational Diabetes, Steroid Induced Diabetes Performance Not Met 2000F-8P – no BP recorded, reason not identified 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

© 2013 McKesson Corporation. Confidential and proprietary. Diabetes Composite: Tobacco Non Use GPRO 315 DM 12 ACO-25 MEASURE Patient age 18-75 presents for an office visit with Dr. Smith and has a diagnosis of diabetes Meets Performance 4004F—Patient screened for tobacco use, identified as a tobacco user and received tobacco cessation intervention OR 1036F—Patient screened and identified as Tobacco Non User Performance Exclusion 4004F-1P – screening not performed for medical reasons (terminal, other) Other exclusions: PCO, Gestational Diabetes, Steroid Induced Diabetes Performance Not Met 4004F-8P – Patient screened and identified as a tobacco user but no intervention documented, or, patient not screened for tobacco use 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Performance Exclusion Performance Not Met Diabetes Composite: Daily Aspirin Use for Patients with Diabetes and/or Ischemic Vascular Disease GPRO 314 DM 14 ACO-26 MEASURE Diabetic patient age 18-75 with documented daily aspirin use or antiplatelet medication use during measurement year, unless contraindicated Meets Performance Codes are available to document aspirin use in IVD and CAD but not in Diabetes. Performance Exclusion Performance Not Met 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

© 2013 McKesson Corporation. Confidential and proprietary. Disease Module Diabetes Control -1 Measure Not part of Diabetes Composite 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

© 2013 McKesson Corporation. Confidential and proprietary. Diabetes Mellitus: Hemoglobin A1c poor control in Diabetes Mellitus #001 ACO-27 MEASURE Patient age 18-75 presents for an office visit with Dr. Smith and has a diagnosis of Diabetes. This is a “reverse” measure (you don’t want to meet this performance measure) Meets Performance 3046F—Most recent Hemoglobin A1c level >9.0% 3046F-8P – Hemoglobin A1c not measured, reason not specified Performance Exclusion 3046F-1P : Polycystic Ovary, Gestational Diabetes, Steroid Induced Diabetes Performance Not Met 3044F—Most recent Hemoglobin A1c Level <7.0% OR 3045F—Most recent Hemoglobin A1c level 7.0- 9.0% 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Disease Module Hypertension Control - 1 measure 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Performance Exclusion Performance Not Met Hypertension (HTN): Controlling High Blood Pressure #236 ACO-28 MEASURE Patient age 18-85 presents for an office visit with Dr. Smith and has a diagnosis of HTN Meets Performance G8752—Most recent systolic BP <140 mmHg, OR G8753 – Most recent systolic BP >140 mmHg, AND G8754—Most recent BP <90 mmHg OR G8755— Most recent BP >90 mmHg Performance Exclusion ESRD, Pregnancy Performance Not Met G8756—BP not documented, reason not identified 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Disease Module Ischemic Vascular Disease-2 measures 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

© 2013 McKesson Corporation. Confidential and proprietary. Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Lipoprotein (LDL-C) Control #241 ACO-29 MEASURE Patient 18 years and older with a diagnosis of Ischemic Vascular Disease or a prior discharge for AMI, CABG or PTCA, and received at least one lipid profile in past 12 months with an LDL<100. Meets Performance G8593—Lipid panel results documented and reviewed (must include total cholesterol, HDL-C, triglycerides and calculated LDL-C) AND G8595—Most recent LDL-C<100 mg/dL OR G8593—Lipid panel results documented and reviewed (must include total cholesterol, HDL-C, triglycerides and calculated LDL-C)Most recent LDL-C >100mg/dL G8597—Most recent LDL-C>100 mg/dL Performance Not Met G8594—Lipid profile not performed 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Performance Exclusion Performance Not Met Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic #204 ACO-30 MEASURE Patient 18 years and older with a diagnosis of Ischemic Vascular Disease or a prior discharge for AMI, CABG or PTCA. Meets Performance G8598 – documented use of aspirin or antiplatelet medication Performance Exclusion 4086F-1P – contraindication or medical exclusion to use of aspirin or antiplatelet medication: on anticoagulant Rx, hx of GI or intracranial bleed, ASA allergy, NSAID’s Rx, uncontrolled HTN (>180 or >110), other physician documented reason 4086F-2P – patient refuses Performance Not Met G8599 – no documented use of aspirin or antiplatelet medication 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Disease Module Heart Failure - 1 measure 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Other Performance Exclusion Performance Not Met Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) #008 ACO-31 MEASURE Patient presents for an office visit with Dr. Smith and has a diagnosis of Heart Failure Meets Performance G8450—Beta-blocker therapy prescribed Other Performance Exclusion G8451—Clinician documented patient with left ventricular ejection fraction (LVEF) <40% or documented as moderately or severely depressed left ventricular systolic function was not eligible for beta-blocker therapy (low BP, asthma, patient refused, intolerance) Performance Not Met G8452—Beta-blocker therapy not prescribed The ACO Quality Measures Sheet doesn’t’ have this metric. Need to add. 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

© 2013 McKesson Corporation. Confidential and proprietary. Composite Disease Module Coronary Artery Disease 2 measures as 1 composite All or Nothing Scoring 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Medical Performance Exclusion Performance Not Met Coronary Artery Disease (CAD): Lipid Control #197 ACO-32 MEASURE % of patients 18 year and older with a diagnosis of CAD seen within a 12 month period who had a LDL-C <100, OR, patients with a LDL-C >100 and have a documented plan to achieve goal including at a minimum a statin Rx Meets Performance G8736—Most current LDL-C <100 mg/dl OR, G8737—Most current LDL-C >100 mg/dl AND 0556F—Plan of care to achieve lipid control documented Additional option with 0556F: 4013F—Statin therapy prescribed or currently being taken Medical Performance Exclusion G8737—Most current LDL-C >100 mg/dl, AND 0556F—Plan of care to achieve lipid control documented, AND 4013F-1P—Documentation of medical reason(s) for statin therapy not prescribed or currently being taken (e.g., allergy, intolerance to statin medication(s), other medical reason(s), OR 4013F-2P – Patient refuses statin Performance Not Met G8737— G 8737-Most current LDL-C >100 mg/dl, AND 0556F-8P – no plan documented OR G8943—LDL-C result not present or not within 12 months prior 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance Other Performance Exclusion Performance Not Met Coronary Artery Disease (CAD): ACE or ARB Therapy for Patients with CAD & Diabetes and/or CAD & Left Ventricular Systolic Dysfunction (LVSD) #118 ACO-33 MEASURE % of patients 18 year and older with a diagnosis of CAD & Diabetes and/or CAD & LVSD seen within a 12 month period Meets Performance G8473 – CAD & Diabetes: Clinician-prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy G8935 – CAD & LVSD: Clinician Prescribed angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy Other Performance Exclusion G8474 – CAD & Diabetes: ACE or ARB not prescribed for reasons documented by the clinician G8936 – CAD & LVSD: ACE or ARB not prescribed for reasons documented by the clinician Performance Not Met G8475 – CAD & Diabetes: ACE ARB therapy not prescribed, reason not documented G8937 – CAD & LVSD: Clinician did not prescribe ACE/ARB therapy, reason not given This metric needs clarification on the ACO Quality Spreadsheet. 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Care Coordination/Patient Safety 2 Measures 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Meets Performance* Performance Not Met* Medication Reconciliation: Reconciliation After Discharge from an Inpatient Setting #46 ACO-12 MEASURE Patient presents for an office visit for follow-up with Dr. Smith within 30 days of an inpatient hospital stay (*Codes below represent 60 day period – will update if new codes are developed, or, use of Transitional Care Codes 99495 or 99496 may suffice) Meets Performance* 1110F - Patient discharged from an inpatient facility within the last 60 days. AND 1111F- Discharge medications reconciled with the current medication list in outpatient medical record (document keeping the same or changing meds/ dosages) Performance Not Met* 1111F-8P - Discharge medications not reconciled with the current medication list in outpatient medical record 39 11/6/2018 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary. © 2013 McKesson Corporation. Confidential and proprietary.

© 2013 McKesson Corporation. Confidential and proprietary. Falls: Screening for Future Fall Risk #318 ACO-13 MEASURE Patient 65 years or older screened annually for falls risk (Any falls within the prior year? If so, were there any fall related injuries?) Meets Performance 3288F—Falls risk assessment documented AND 1100F—Patient screened for future fall risk Other Performance Exclusion 3288F-1P—Falls risk assessment not documented due to bedridden, immobile, or other reason Performance Not Met 3288F-8P – Patient not screened for future fall risk 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

Primary reference CMS-Measures Description Narrative http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2013_PQRS_IndClaimsRegistry_MeasureSpec_SupportingDocs_12192012.zip CMS-Measures Description Narrative http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/sharedsavingsprogram/Quality_Measures_Standards.html

Office Workflow Suggestions: Identification of ACO Patients within Workflows Use attribution lists Implement EMR “Health Maintenance Reminders” or other checklist that identifies/automates CPT 2 code submission on claims Annual Medicare Wellness Visit Templates that include ACO metrics and CPT 2 codes Physician/Provider & Staff Responsibilities: Office Clinical Coordinator – gaps in care management (patient registry/spreadsheet, physician portal, labs)/ patient outreach Clinical Staff – automated orders (screenings, immunizations, labs, follow-up plans) Physicians/Providers – Patient Care Plans, treat to goals Specialists – mammograms, colonoscopies, disease-specific metrics 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.

© 2013 McKesson Corporation. Confidential and proprietary. Questions? 11/6/2018 © 2013 McKesson Corporation. Confidential and proprietary.